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International Orthopaedics (SICOT) (2015) 39:769775

DOI 10.1007/s00264-014-2539-z

ORIGINAL PAPER

Arthroscopic partial meniscectomy is superior to physical


rehabilitation in the management of symptomatic unstable
meniscal tears
Sherif A. El Ghazaly & Amr A. Abdul Rahman &
Ahmed H. Yusry & Mahmoud M. Fathalla

Received: 18 June 2014 / Accepted: 15 September 2014 / Published online: 10 October 2014
# SICOT aisbl 2014

Abstract Conclusions Pain and swelling improved after physical ther-


Purpose Meniscus injuries are the most commonly reported apy. However, patients were not satisfied as limited range of
in athletes. Meniscectomy is the most common treatment. knee motion persisted. APM was superior to physical therapy
Stable peripheral tears may heal, while degenerative tears in treating symptomatic unstable meniscal tears, with high
do well with physical therapy. However, the exact role of patient satisfaction and restored knee function.
physical therapy in treating symptomatic unstable meniscal
tears is not known. We aimed to identify the role of physical
Keywords Partial meniscectomy . Unstable tear . Meniscal
therapy in treating such patients and clarify the role of arthro-
tear . Physical therapy . Meniscectomy
scopic partial meniscectomy in treating unstable meniscal tears.
Methods Seventy patients with unstable meniscal tear met the
inclusion criteria according to Vande Berg and co-workers.
Clinical examination, McMurray test and magnetic resonance Introduction
imaging were done. Age ranged from 1867 years (average
39.87). Mild osteoarthritis was seen in 20 cases. Physical Meniscal injuries are reported to be the most common injury
therapy thrice a week for eight weeks was offered (faradic sustained by athletes, but sports injuries account for only 30 %
quadriceps stimulation and neuromuscular strengthening of all meniscal lesions. Meniscectomy is the most common
exercises). After physical therapy, patients still complaining procedure performed by orthopedic surgeons for such injury.
or unsatisfied were offered arthroscopic partial menisectomy However, the appropriate treatment of meniscal tears depends
(APM). Outcomes were evaluated using the VAS pain score on many factors. Tear type, location and tissue quality may
and the Lysholm knee score. dictate treatment type and outcome. The presence or absence
Results Mean VAS before interventions was 7.4, significantly of osteoarthritis and the degree of arthritis may allow or
improved to 5.16 after rehabilitation and to 1.9 after APM (p= obviate arthroscopic meniscectomy.
0.001). Mean Lysholm score before rehabilitation was 65.1 Unstable meniscal tears cause mechanical symptoms,
and improved to 69.6 after rehabilitation, the difference was while synovial irritation can cause repeated effusion. Both
non-significant. However, Lysholm score difference before may prevent full knee flexion, which is sometimes incapaci-
and after APM showed a highly significant difference tating in the Asian population. Symptomatic unstable
(p=0.001). meniscal tears warrant excision, while stable peripheral tears
can heal without surgery. The goal of arthroscopic partial
meniscectomy (APM) is to preserve a stable meniscal rim,
S. A. El Ghazaly (*) : A. A. A. Rahman : A. H. Yusry
removing only unstable, diseased tissue [1]. Yet, some authors
Orthopedic Surgery Department, Ain Shams University Hospital, reported increase in radiographic evidence of arthritis years
Ain Shams University, Cairo, Egypt later. Thus, arthroscopic menisectomy for meniscal tears is
e-mail: sherifghazaly@hotmail.com still debated [13]. However, in patients with meniscal tear not
undergoing surgery, 30-month follow-up study showed
M. M. Fathalla
Physical Medicine and Rehabilitation, Ain Shams University, Cairo, meniscal damage to be a potent risk factor for the development
Egypt of radiographic osteoarthritis [4].
770 International Orthopaedics (SICOT) (2015) 39:769775

In spite of pain and mechanical symptoms, many patients try Lawrence grade 2 or less). Exclusion criteria were acute
to avoid undergoing surgery. Recently, physical therapy (PT) locked knee, ligament injury, or knee surgery within the
has been advised to treat meniscal tears. This seems a sound previous two years. There were 30 women (42.8 %) and 40
option for patients unwilling to be operated upon. Several men. Age ranged from 18 to 67 (average 39.87 years). All
reports have proposed physical therapy to treat degenerative cases were examined clinically and McMurray test was done.
meniscal tears [57]. Most surgeons use physical therapy after The right side was involved in 70 % of the cases. There were
arthroscopic surgery. However, the exact role of physical thera- 49 (73 %) medial meniscal tears and 21 lateral tears. Radio-
py in treating symptomatic unstable meniscal tears is not known. graphic evidence of osteoarthritis was seen in 20 cases
sters et al. [6] postulated that exercise dosage given is (28.5 %) (Kellgren-Lawrence grades 1 or 2) [9]. All cases
related to decrease in pain and swelling and improved neuro- were offered physical therapy sessions thrice a week for
muscular function. We hypothesized that physical therapy, eight weeks, consisting of faradic stimulation to quadriceps
through resolving knee swelling, improving pain and range muscle (pulse duration=1 ms, pulse interval=500 ms) and
of motion, restoring muscle strength and improving quality of neuromuscular and strengthening exercise program [5, 6].
movement performance, may be an effective alternative ther- The exercise program was performed in the gym of the
apy for patients with unstable symptomatic meniscal tears. physical medicine and rehabilitation department at Ain Shams
The aim of this work was to identify the role of physical University hospital. The exercise program and exercise pro-
therapy when treating patients with unstable meniscal tears gression strategy were explained individually to the patients.
and clarify the role of surgical arthroscopy. Subjects were informed that they could withdraw from the
study at any time. All patients were instructed and supervised
by the same physiatrist thrice a week throughout the program
Patients and methods to ensure the intended performance of exercises and progres-
sion for each individual.
The methodology of this prospective study was approved by The exercise program began with a warm-up on a station-
the research ethical committee of Ain Shams faculty of med- ary bike for ten minutes using the resistance level of choice
icine and all patients provided a written informed consent and concluded with another ten minutes at the end of the
prior to participation. This study included seventy patients session. The remaining exercises were initially performed with
clinically diagnosed as having unstable meniscal tear which low-dose, low repetitions, then gradually increased according to
was documented by magnetic resonance imaging (MRI) ac- the patients tolerance. The exercise program included: step-up;
cording to the criteria of Vande Berg et al. [8], defined as knee stability to maintain balance; hamstring on fitball, where
displaced meniscal fragment, visible on more than two sagittal both feet were placed on top of the ball then the back and pelvis
and three coronal images, having more than one orientation were lifted and the patient pulled the ball towards himself;
plane, and showing intrameniscal high signal intensity on T2- single-leg press,starting with 90 knee flexion; single-leg knee
weighted images. All patients were recruited from the ortho- extension, starting in 90 of knee flexion; single-leg leg curl,
pedic and physical medicine departments of Ain Shams Uni- where a weight was lifted quickly up and then slowly down. In
versity Hospitals during the period from 2009 until 2012. all exercises, knee flexion or extension was performed to the
Inclusion criteria were persistent knee pain despite range the patient can tolerate. After completion of this program,
four weeks of rest, activity modification and medical treat- patients still complaining or unsatisfied were offered arthro-
ment, tenderness on the joint line, positive McMurray test, tear scopic partial menisectomy.
documented on three consecutive sections of sagittal MRI After pre-operative antibiotics and tourniquet control,
(Fig. 1) and absence of advanced osteoarthritis (a Kellgren- anteromedial and anterolateral portals were created, and both

Fig. 1 T2-weighted sagittal MRI showing a vertical tear of the medial meniscus on three sections
International Orthopaedics (SICOT) (2015) 39:769775 771

menisci were examined. Limited synovectomy was done in was set at p value<0.05, while p value <0.01 was highly
order to allow visualization in both knee compartments. Any significant.
unstable meniscal tissue was excised and trimmed back to a
stable meniscal rim. Weight bearing was started as tolerated.
Outcomes were assessed using the 10-cm visual analogue Results
scale (VAS) and Lysholm knee score [10]. The VAS for pain
was recorded before and after physical therapy and six weeks Mean VAS before interventions was 7.41.1, and improved to
after arthroscopy. The Lysholm knee score demonstrated ac- 5.161.75 after the rehabilitation program (p=0.001) and 1.9
ceptable psychometric performances as outcome measure for 0.93 after APM (p=0.001), (Fig. 2). Mean Lysholm score
patients with meniscal injury [11], and was recorded before showed a non-significant improvement from 65.1 to 69.6 after
physical therapy, before and after arthroscopy and at final rehabilitation. This value improved to 87.9 after APM, and to
follow-up. Range of motion, McMurray test and patient sat- 90.5 at final follow-up (p=0.001) (Fig. 3). Multivariate re-
isfaction were recorded. A minimum follow-up of six months gression analysis between various parameters and the final
was ensured (range, six to 24 months). Average follow-up was Lysholm score showed a significant difference only for pres-
12.5 months. ence of osteoarthritis (p=0.001), whereas follow-up period,
age and sex showed no significant difference. Further, com-
paring arthritic versus non-arthritic patients, outcome scores
were consistently better for non-arthritic cases (Table 1). Com-
Statistical analysis paring medial versus lateral meniscal tears using the paired t-
test, statistically significant differences were detected only in
The data was revised, encoded and tabulated then entered into mean VAS score and mean Lysholm knee score after PT. Also
a personal computer using the Statistical Package for Social results showed improvement of both scores for medial and
Sciences software (SPSS) version 18 (Chicago, IL). Numeric lateral menisci after APM but without statistical significance
data were described as meanstandard deviation (SD). Non- (Table 2).
numeric data are shown as frequencies and percentages. Patients undergoing physical therapy noticed improved
Paired t-test was used to analyze differences of mean VAS pain and swelling. Pain recurred seven to ten days after
before and after interventions. Differences of the mean completing the program, especially with deep knee bends.
Lysholm score were analyzed using the F-test. Significance Full knee flexion or extension was not possible. After APM,

Fig. 2 VAS for the study cohort


pre-physiotherapy versus post
physiotherapy and pre-scope
versus post scope. Values are
presented as median (interquartile
range)
772 International Orthopaedics (SICOT) (2015) 39:769775

Fig. 3 Lysholm score before


APM, after and at final follow-up.
All values are presented as
median (interquartile range)

knee range improved and burning pain within the knee was Discussion
reported with gradual daily improvement, as well as pain at
the portals which also subsided gradually after surgery. Pain To our knowledge, this is the first report studying the role of a
subsided completely within two to four weeks. Patient satis- standardized physical therapy program versus APM in the
faction following APM and physical rehabilitation was 85 % management of symptomatic unstable meniscal tears. Pain
vs 57 % respectively regarding pain, 88 % vs 92 % respec- and swelling improved after physical rehabilitation but pa-
tively regarding swelling and 90 % vs 35 % respectively tients were not fully satisfied because pain recurred and lim-
regarding function, with 60 % overall patient satisfaction after ited range of motion of the knee persisted. APM was superior
PT. At final follow-up, overall patient satisfaction following to physical rehabilitation with high patient satisfaction and
APM was 87 % (61/70). Six months after surgery, 80 % restored knee function.
had returned to their previous activity levels. Complications
included transient knee swelling (three cases), superficial
infection needing antibiotics (one case) and mild vastus
Table 2 Differences of mean VAS score and mean Lysholm knee score
medialis weakness (three cases). before and after interventions when comparing medial versus lateral
meniscal tears using the paired t-test
Table 1 Differences of VAS score and Lysholm knee score before and
after interventions for patients with and without osteoarthritis using the Parameter Medial Lateral p value
paired t-test meniscus meniscus

Parameter: Osteoarthritic Non-arthritic p value Follow-up time 11.26 12.22 0.52


(n=20) (n=50)
VAS before PT 7.61 6.84 0.01a
VAS before physiotherapy (PT) 8.2 7.08 0.001 VAS after PT/Before APM 5.51 4.21 0.005b
VAS after PT/Before scope 6.2 4.74 0.001 VAS after APM 1.96 1.74 0.37
VAS after APM 2.2 1.78 0.09 Lysholm knee score before APM 68.43 72.74 0.03a
Lysholm knee score before PT 60.1 67.3 0.001 Lysholm knee score after APM 87.27 89.74 0.09
Lysholm knee score before APM 63.7 71.96 0.001 Final Lysholm knee score 89.96 92.21 0.1
Lysholm knee score after APM 83 89.92 0.001
a
Final Lysholm knee score 84.8 92.88 0.001 Statistically significant
b
Highly significant
International Orthopaedics (SICOT) (2015) 39:769775 773

Meniscectomy is the most common procedure performed strengthening exercises. This protocol reduced swelling and
by orthopedic surgeons, [12] with an incidence of 61 per pain, and improved range of motion, but full knee flexion was
100,000 per year. [13]. While it is still debated if a degener- not restored. Sessions were attended three times weekly, in
ative horizontal tear should be treated surgically [2], unstable contrast to once weekly sessions in the study of Katz et al. [18].
tears, like flap tears, usually need surgical intervention. Some Several studies reported non-operative treatment to be a
studies reported use of physical therapy to treat degenerative reasonable first strategy [7, 18, 19], with surgery reserved for
tears, while others used physical therapy only after patients not showing improvement [7]. The current study
meniscectomy. However, the efficacy of physical therapy in contradicts this, since patients were not satisfied with physical
patients with symptomatic meniscal tears is unproved [7]. therapy alone and underwent APM.
While some authors consider horizontal tears unstable, Yim Arthroscopic debridement was compared to non-operative
et al. [2] consider them stable. In a study of meniscectomy treatment among osteoarthritic patients in two randomized
versus non-operative treatment for degenerative horizontal me- controlled trials [1821]. After two years, neither trial showed
dial meniscal tear, no differences were found in terms of knee any significant or clinically important difference between
pain relief, improved knee function, or increased satisfaction arthroscopic and non-operative groups regarding functional
after two years of follow-up [2]. Although the work by Yim improvement or pain relief [20, 21], emphasizing that arthro-
et al. [2] implies only a limited role for menisectomy, our results scopic treatment was not superior to other interventions in
showed statistically significant improved knee pain after both treating knee osteoarthritis. However, they did not focus on
physical therapy and APM. However, significant patient satis- management of a symptomatic meniscal tear, which is a
faction and improved knee function were evident after APM, as frequent indication for knee arthroscopy in patients with os-
evidenced from the sustained improvement of the Lysholm teoarthritis of the knee. The efficacy of APM in symptomatic
score, which improved to 87.9 after APM and to 90.5 at final patients with a meniscal tear and osteoarthritis was evaluated
follow-up (p=0.001). in a randomized, controlled, single-center study involving 90
Dervin et al. [14] found mechanical symptoms unreliable patients. This showed no significant difference in pain relief or
predictors of unstable meniscal tear. The only positive predic- functional status between APM plus physical therapy versus
tor was a positive McMurray test, thus we relied on a positive physical therapy alone [17]. However, patients in this cohort
McMurray test to clinically detect unstable meniscal tears. were osteoarthritic. Herrlin et al. [19] reported 33 % of pa-
Meniscal tear may cause pain, effusion, muscle weakness, tients treated using exercise therapy alone felt no better after
and limited range of motion. The goals of physical therapy are to treatment and still had disabling knee symptoms that im-
obtain painless full range of motion, improve muscle strength, proved after arthroscopic surgery.
balance and function [15]. While knee pain may cause quadri- Most articles studied the effect of APM on arthritic knees
ceps weakness, [16] physical training and neuromuscular exer- [7, 18, 21]. Katz et al. [18] studied patients with osteoarthritis,
cises play an important role in reducing symptoms, improving while in the current study, only 28.5 % had mild arthritis,
muscle strength, physical ability and quality of life in patients possibly explaining our better results.
with medial meniscus tears [17]. In this study, all patients Between six to12 months, 34.9 % of 169 patients crossed
underwent a standardized physical therapy protocol, consisting over from physical therapy to APM, [18] indicating the degree
of faradic quadriceps stimulation and neuromuscular of patient dissatisfaction with physical therapy alone. This is

Fig. 4 Treatment algorithm for Unstable meniscal tear


patients with unstable meniscal
tears

Physical therapy (8 weeks)

No improvement Improved

Un-satisfied Satisfied
and/or
OA < /= grade 2 OA > grade 2
Symptoms
recurred

APM OTHER TTT


774 International Orthopaedics (SICOT) (2015) 39:769775

explicitly mentioned by the authors and is in agreement with Sihvonen et al. [25], comparing APM to sham surgery for
our findings that patients in this study were not fully satisfied degenerative medial meniscus tears, found no difference be-
with physical therapy alone. Also, comparing the average tween the two interventions, contradicting with findings in the
Lysholm scores before and after surgery for arthritic versus current study. However, this may be explained by the placebo
non-arthritic patients, better results were found in non-arthritic effect of surgery for the sham group. Also, when comparing
cases (p=0.001) (Table 1). patients before and after APM, this study showed improve-
At 6 months, WOMAC score improved in 67.1 % of ment in the Lysholm knee score in this group [25].
patients assigned to APM versus 43.8 % of patients assigned While it is generally believed that meniscal tissue loss may
to physical therapy as reported by Katz et al. [18]. We report lead to osteoarthritis and poor knee function, many variables
significant improvement of the Lysholm score after APM, influence meniscectomy outcome [12]. Although Petty and
which was sustained up to the final follow-up. A small num- Lubowitz report favorable short-term results of APM [1], we
ber of patients showed limited improvement of the Lysholm need to review our patients after five years, to identify any
score, possibly attributed to osteoarthritis, poor quality of progression to osteoarthritis. Also, an algorithm for treatment
meniscal tissue and associated chondral damage. Katz and decision in cases with unstable meniscal tear is proposed
co-workers report 59.5 % cross-over from physical therapy (Fig. 4).
to APM across study centres. These patients showed no sub-
stantial functional improvement until cross-over [18].
A study on effects of surgery versus non-operative treat-
Conclusions
ment in patients with osteoarthritis concluded that arthroscop-
ic surgery was not more effective than non-operative treat-
Physical therapy alone was not sufficient to treat unstable
ment, which included physical therapy (one session per week
meniscal tears. Arthroscopic partial menisectomy provided
for 12 weeks), patient education, and stepwise use of acet-
effective treatment, with high patient satisfaction and restored
aminophen, anti-inflammatory drugs, glucosamine, and local
knee function, even in the presence of grade 2 osteoarthritis.
hyaluronic acid [21]. In their study, it was not possible to
isolate the effects of the various non-operative modalities. In
fact, the use of several drugs that may have improved pain and
Conflict of interest The authors declare that no funding or grant was
other symptoms may be a reason why surgery appeared no received for the study, and that they have no conflict of interest, nor
better than non-operative therapy. financial or personal relationship related to the study.
In patients with concomitant osteoarthritis, disease-related
pain can persist after arthroscopic surgery [22]. Osteoarthritis
patients having chondral or osteochondral lesions may not be
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